Roughly 100 years ago, well before the counties of Brunswick and Pender were the fast-growing locales they’ve become in the past 25 years, they were sleepy areas dotted mainly with farms, small towns and almost no doctors.

In fact, Brunswick County was served by two physicians, William Goley of Shallotte and J. Arthur Dosher of Southport, who typically set out on horse-and-buggy, 200-mile-a-week treks to treat patients. Dosher in particular demonstrated where “modern” medical care might go, performing surgeries on his kitchen table and keeping patients in recovery in the basement of his Southport home.

Brunswick County Health Services was formed in 1924 with the goal of building a public hospital; Brunswick County Hospital, the precursor to Dosher Memorial Hospital, opened in 1930 with funding from the Duke Endowment, local taxes, bond levies and donations. Dosher and Goley were the first two doctors at Dosher Memorial Hospital, a critical access hospital.

Today, Dosher’s dining room table surgical procedures have been replaced by a host of advancements, such as telehealth-driven improvements such as round-the-clock access to neurologists for stroke patients and orthopedic surgery utilizing robotic arm assist. Incorporating state-of-the-art technology is important, but only a partial solution to rural healthcare problems.

The complex healthcare issues facing rural communities in the Wilmington-area counties of Brunswick and Pender revolve around several, often interlocking factors. They include rising overall costs, the threat of reduced Medicare and Medicaid funding, uninsured and underinsured residents, transportation from more remote areas and chronic doctor shortages.

Simple, foolproof solutions simply don’t exist, but hospitals, clinics, nonprofits and health and human services departments in both counties have had to adopt innovative approaches and a collaborative philosophy of “we’re all in this together.”  For example, mental health and behavioral services demand flexibility to ensure viable patient access.

Lack of insurance and transportation challenges are just two of several related factors, said Rakhee Patel, regional adult clinical director for Wilmington-based Coastal Horizons. The nonprofit provides evidence-based substance use, mental health, crisis intervention, justice and wellness services to people in need. Patel oversees adult behavioral services in Brunswick, Pender, Bladen and Columbus counties.  

“In 2023, we opened a mobile health clinic in Navassa for residents in the north Brunswick County area,” she said. “It was definitely slow going at first, but some of that is a natural function of building community trust. We were able to do that, and we’ve now been able to add primary care services.   

“But you know we had to keep in mind that there are transportation challenges. Brunswick is a large county; it’s not unusual for people to drive 30 minutes just to get to their scheduled appointment, so we don’t want that to be a barrier to services. Also, many of our community partners are on Medicaid, so one option that we might utilize is Medicaid-connected transportation.”  

Patel points out that Coastal Horizons is seeing who she terms the “most complex individuals,” meaning those who are higher risk, dealing with a constellation of issues that might include active substance use, more significant mental health and medical issues and sometimes homelessness.  

One of the key attributes of Coastal Horizons’ program is the linked aspects of privacy and comfort level, explaining that “people find out that when they come in for their appointment at a mobile clinic, they know they’re not going to sit in a waiting room. We also will commonly connect them with a peer support specialist, someone who has genuine lived experience in either the mental health or substance abuse areas.”  

Telehealth is another option for patients facing common obstacles that make in-person appointments problematic, Patel said.   

“This mode allows our community partners to have true continuity of care if their provider – whether a therapist, psychiatric or primary care provider – is unavailable on-site,” she said.  

David Howard, Brunswick County’s health director, agrees that mental and behavioral health is a must-have component of the overall health of the adult and child populations in the county.    

“Across the community,” he said, “we have to recognize the importance of continuous mental health and wellness. 

“That means improving access to treatment and levels of professional or paraprofessional care, or peer-led programs,” he added. “The challenge is to help our residents learn the resources that are available, including providers, their services and fees. The reality is that we still have a shortage of doctors in our more rural areas.”  

Additionally, the department offers a range of programs and services for various populations, including children’s and women’s health, diabetes programs and nonemergency medical transportation. A comprehensive health clinic in Bolivia offers programs such as family planning, women’s preventive health, immunizations and tuberculosis screening.  

The chronic shortage of doctors that Howard alludes to in rural areas hampers the quality of and access to care. But promising initiatives designed to build a sustainable system could increase access to primary care doctors, officials said. One of those is a family medicine residency program, launched in 2025, affiliated with Novant Health Pender Medical Center in Burgaw.   

For the residency program, the hospital partners with Black River Health Services, a clinic started over 50 years ago with three locations in Pender County and a higher ratio of uninsured and underinsured patients.   

Ruth Glaser, president of Novant Health Pender Medical Center, highlights the 2022 grant the hospital received that helped the rural residency program get rolling in training and retaining doctors in their high-need area. Glaser said retaining residents starts with the act of “having them do their training in a less hectic training environment, appealing to those who grew up in a small town or a rural environment.” 

“And it’s true that a resident can make a difference in the lives of underserved people who will benefit from expanded care they may not have experienced before,” she said. “There is, in fact, research supporting that wherever you train is where you stay.”  

Black River Health Services, in addition to its status as a Federally Qualified Health Center (FQHC) Look-Alike, is a nonprofit family practice, offering affordable, accessible primary care, mental health services and a Medical Access program. This program opens the doors for underserved, uninsured or Medicare/Medicaid patients, officials said.  

Black River Health Services CEO Lee Ann Amann communicates a vibe of community commitment – and to the underserved population that she said “deserves affordable, compassionate care” – with a stern side-eye for the habitually threatened dilution of programs such as Medicaid. Practices like Black River Health Services function in an environment where Medicaid’s presence is underestimated.   

Three of many fast facts: Medicaid covers 1 in 4 North Carolinians, which equates to 3 million people; 50% of all births in the state are covered by state Medicaid; and in many rural counties, more than half of the population has health coverage through state Medicaid.  

“Children mainly are on Medicaid,” Amann said. “We want all children to be healthy, so we need an attitude transformation in America that it is, you know, a right?”  

Not surprisingly, she has similarly strong words when making the case for rural hospitals and health facilities.   

“So many families want to move to a less-populated area,” Amann said, “but what if there is insufficient health care coverage? What about delivering a baby in a rural area without an obstetrician? Or if you have a heart attack?”  

Black River Health Services is supported by an 11-person, volunteer board led by Martha Highsmith, an Atkinson native who spent nearly 40 years in education and ministry, including serving as senior pastor of the Yale University campus church, before returning to Castle Hayne in 2017.  

“Just as Black River holds a patient-centered approach to rural health, our board is focused on being good stewards,” she said. “The thing about rural health is it’s medicine, but it’s all about relationships.”  

Looking back and looking ahead, she recalls seeing her farmer dad looking up in the sky, trying to suss out what the clouds, weather and wind he was experiencing meant: a coming storm, a passing front or even a tornado.  

“Remembering that,” she said, “it’s somehow like the process we go through as we try to figure out what all the change and challenges in rural health actually mean. There’s a lot of turmoil within rural health, and it’s incredibly worthwhile to understand it.”